Early Enrollment Spring 2015 Promotion

Membership Application

SSN (all digits are desired, last 4 digits are required) / EMPLOYEE ID # / LOCAL ASSOCIATION
MR. ¨ MISS ¨ DR. ¨
MRS. ¨ MS. ¨ / FIRST / MIDDLE / LAST
ADDRESS
CITY / STATE / ZIP CODE
HOME PHONE / CELL PHONE / HOME EMAIL / WORK EMAIL
HIRE DATE / ETHNICITY (optional) / DATE OF BIRTH / GENDER
WORK LOCATION / POSITION / SUBJECT

The following information is REQUIRED:

Have you been a member of NEA in the past? / / Check
One:
2015-16 Salary: /
How would you like to receive your MSEA ActionLine magazine? ¨ Print ¨ Digitally

As a participant in the local association(see above)/Maryland State Education Association/National Education Association Early Enrollment Membership Incentive Plan, I am eligible to receive prior to September 1, 2015 (but in no event before April 1, 2015) benefits under the NEA Educators Employment Liability (EEL) Program, as well as access to select NEA Member Benefits programs. As a condition of eligibility for these benefits, I agree to pay the appropriate unified Active membership dues for the 2015-2016 membership year in accordance with established payment procedures. Should I fail to do so, my eligibility to receive benefits under the NEA EEL Program shall immediately terminate. In addition, I shall be liable for the cost of any benefits that were provided to me under the NEA EEL Program prior to September 1, 2015.

EEL Program coverage from date of signature below (April 1, 2015 through August 31, 2015) is available only to individuals who are joining the Association for the first time as Active members for the 2015-2016 year.

Payroll Deduction Authorization: I authorize continuing payment or deduction of dues in the sum determined by my local affiliate, the Maryland State Education Association and the National Education Association, each year, unless I revoke this authorization in writing to my local affiliate by such time as is designated in my local affiliate’s collective bargaining agreement or my local affiliate’s policy. In case of my resignation or termination, the board of education shall deduct the balance of my yearly dues from my final check. Dues payments are not deductible as charitable contributions for federal income tax purposes.

SIGNATURE______DATE ______

Yes! I want to see our elected officials stand up for public education and my students. I hereby authorize the following contribution to the Fund for Children and Public Education of NEA, MSEA, and my Local Association to build a strong voice for educators:

TOTAL PAC PAYROLL DEDUCTION PER PAY PERIOD ¨ $6.00 ¨ $3.00 ¨ $1.50 ¨ $______SIGNATURE______

The NEA, MSEA and applicable local Funds for Children and Public Education (FCPE) collect voluntary contributions from Association members and use those contributions for political purposes, including but not limited to, making contributions to and expenditures on behalf of friends of public education who are candidates for federal, state and local offices. Contributions to the Fund for Children and Public Education are voluntary; making a contribution is neither a condition of employment nor membership in the Association, and members have the right to refuse to contribute without suffering any reprisal. A member may contribute more or less than the amount suggested above or may elect not to make any contribution and this will not affect his or her membership status, rights or benefits in MSEA, NEA or any of their local affiliates. Contributions to the MSEA Fund for Children and Public Education will be distributed evenly between the NEA FCPE, the MSEA FCPE and the local FCPE. Contributions to the NEA, MSEA, and local Funds for Children and Public Education are not deductible for federal income tax purposes. Federal law requires us to use our best efforts to collect the name, mailing address, occupation, and the name of employer for each individual whose contributions to the NEA Fund for Children and Public Education aggregate in excess of $200 in a calendar year. Federal law prohibits the NEA Fund for Children and Public Education from receiving donations from persons other than members of the NEA and its affiliates and their immediate families. All donations from persons other than members of NEA and its affiliates and their immediate families will be returned forthwith.

REFERRED BY: ______LOCAL ASSOCIATION: ______

RETAIN A COPY FOR YOUR RECORDS